In health terms, ‘prevention’ basically means doing stuff that reduces risks to health. Primary prevention focuses on the whole population to stop a problem occurring in the first place, for example through immunisation or discouraging smoking; secondary prevention focuses on at-risk individuals and aims to nip an issue in the bud by detecting and treating it as soon as possible, like we do with screening programmes; and tertiary prevention aims to reduce the impact of an existing condition and maximise a person’s quality of life, for example through rehabilitation and ongoing support to help them manage their condition. These definitions can just as easily be applied to other things like crime, injuries, addiction or violence.
The Government released their Prevention Green Paper in July, to what I might generously call mixed reviews. There is some decent stuff in it but, as usual, it focuses mainly on secondary and tertiary prevention. Most of the criticism was therefore around its failure (once again) to address the root causes of poor health. It briefly mentions some of the wider determinants of health like housing, debt and transport, but doesn’t offer much in the way of action.
We don’t do nearly enough primary prevention. Proper prevention. Politicians tend to focus on policies like increasing access to mental health services (for those who already have poor mental health) or increasing prison numbers (to lock up people who have already committed a crime), but not on changing the social conditions which make mental illness or crime more likely in the first place. Too much focus on fixing problems and not enough on avoiding them, so we spend a bloody fortune just trying to keep a lid on things. It reminds me of the Red Queen in Through the Looking Glass: “it takes all the running you can do, to keep in the same place”.
The problem with prevention
Perhaps one reason why the Green Paper failed to take off was the term ‘prevention’ itself. This pithy article by Sarah Lawson for the New Local Government Network, whose title I nicked for this bit, does a good job of summarising issues with the term, such as how it makes people think of health only in terms of desperately preventing crap stuff in order to save the NHS some cash, rather than as something to invest in for much wider benefits.
One of my own issues with the primary-secondary-tertiary definition of prevention is its breadth. You can basically count anything as prevention, and that gets policy makers off the hook. It lets them say they’re focussing on prevention when they’re not really. Even palliative care can be considered as tertiary prevention – it’s prevention of further suffering I suppose – but, well, come on…
I’d like ‘prevention’ to be used only for primary prevention. Instead of primary, secondary and tertiary prevention we could have, say, prevention, early identification and intervention, and mitigation. A politician therefore couldn’t take credit for spending a load on prevention through, say, a dubious screening program, because that’s early identification. Palliative care isn’t prevention, it’s mitigation of the effects of a terminal illness. Just semantics perhaps, but if you’ve read my other blogs you’ll know I think that language matters. It would at least make it clear what should – and shouldn’t – be included in a proper prevention strategy. Starting with…
Poverty and inequality
Poverty and inequality are perhaps the ultimate underlying causes of poor health, but they are barely mentioned in the Green Paper. That’s ridiculous really, as the chances of experiencing pretty much anything negative – obesity, being a victim or perpetrator of crime, illness, addiction, suicide, poor educational achievement, whatever – is increased if you are poor.
What’s so insidious about poverty is the long-term lack of freedom and power that it leads to; that constant fight just to scrape by, to afford the basics, to get to work, to keep your children clean and fed and happy. It’s absolutely knackering and demeaning and bloody of course it can end up making you stressed and unhappy and ill, or drive you to drink or despair. If someone has so many challenges in their life, trying to make any positive changes to just one is pretty much impossible, because of pressure from the others. You could pay your bills on time, but then you’d have no money left for food. You could work more hours, but you’re already knackered and the extra wages would go on childcare anyway. The term ‘shit life syndrome’ describes being trapped in this constant cycle of struggle, which leads to countless medical problems that have no medical solutions. As Michael Marmot has so often said, what good does it do to treat people and send them back to the conditions that made them sick?
The potential health benefits from tackling poverty and reducing inequalities outweigh pretty much everything else, yet they are barely touched on in the Green Paper. Whilst we do of course need strategies that focus on individuals and specific health conditions, for primary prevention – proper prevention – we need to focus on policies that change wider social conditions. Nationally, I think we need One Prevention Strategy to Rule Them All, one that does exactly what it says on the tin:
A General Shit Life Reduction Strategy
So what should go in this Strategy? If poverty and inequality are the principal causes then we just need to focus on policies to get more money into the pockets of the poorest, yes? A living wage, a functioning welfare system, perhaps even universal basic income (more on that one later)? That would be part of it, certainly. Organisations like the Joseph Rowntree Foundation are doing great work in this area. My first chapter would definitely be on eradicating poverty. I’d probably just copy and paste the JRF’s stuff to be honest…
We’d also need wider economic policies and again I’d blatantly nick the ideas of people and places that are already doing great work in this area. The idea of an inclusive, wellbeing economy – one in which the ultimate goal is to improve everybody’s health and happiness and not just to add some zeros onto some ethereal bank balance – is taking off. There’s loads to read on this from the New Economics Foundation, the Wellbeing Economy Alliance, What Works Wellbeing and many others. New Zealand are leading on this at national level, whilst closer to home the Scottish and Welsh are well ahead of the UK Government (as they are for so many things…), but there are encouraging signs here too. Local areas in England are doing lots of good work around this and MPs are beginning to get on board, as this report from the All-Party Parliamentary Group on Wellbeing Economics shows. Sheffield DPH Greg Fell has summarised a lot of what’s currently going on, and this Reasons to Be Cheerful podcast is a great, accessible introduction.
I won’t bang on about the points above because (a) it’s glaringly obvious to everybody (apart from those with the power to do anything about it, apparently) that we need to take people out of poverty and reduce the gap between the haves and have-nots, and (b) if the enormobrains of Marmot and the JRF haven’t convinced you by now, then I doubt a blog by an unknown idiot like me is going to.
If we did do these things though, would that be it? Problem solved? No, unfortunately, because inequality is about more than income, as these two articles from the left and right of the political spectrum highlight (ah, common ground between those with different political views, remember that?). Income inequality has barely changed for decades, but the gaps between the richest and poorest in terms of health, wealth, education, crime etc. have increased. The recently-announced IFS Deaton Review will look beyond income at inequalities in health, by gender, ethnicity, and geography.
Speaking of geography, a while ago I wrote a piece about Adverse Childhood Experiences (ACEs) and said:
If generally difficult lives […] are the root cause of ACEs, then I’m not sure we even need distinct ACEs prevention strategies; it’s the same as preventing everything else. What we need is the funding and freedom to develop broad prevention approaches that focus upstream. A living wage. Clean streets. Good, affordable housing. Parks. Stuff for teenagers to do. Welfare. Jobs. Childcare. Good schools. […] Proper help for individuals is absolutely essential, but it’s not really prevention is it? We need to tackle the roots of the problem too.
This is what got me thinking about a general Shit Life Reduction Strategy, but it also occurred to me that many of the things I mentioned in passing – housing, parks, streets, stuff to do – are nothing to do with individuals or income; they’re about our surroundings. Places, things; not people. I’ve become more and convinced that where we live is as important as how we live. The next bit of my strategy (and it is my strategy, right, so I can choose) – will focus on this, and what I’ve started to think of as Shit Life Syndrome’s cousin: Shit Place Syndrome.
Acknowledging ‘Shit Place Syndrome’
A quick thought experiment – two people, same income, one in a nice leafy area and one living in a run-down estate. Who’s more likely to end up ill? What about you, would you rather have a 20% pay rise but live in a bad area, or stay as you are and live somewhere nice? It’s not just about how much money you’ve got in your pocket is it?
The places we live are so important to our wellbeing and I think it’s important to acknowledge when somewhere is just crap, because it can be really bloody hard living somewhere crap. No public transport, nowhere for kids to play, no decent schools, no decent housing, no prospects. It’s absolutely no reflection on the people who live there – they’re generally victims of decisions made by others, poor planning and design, lack of investment, prejudice, neglect; all of which lead to a persistent cycle of deprivation and low aspiration.
Now, I’m all for strengths-based approaches when we are talking about people. Understanding that people and communities have strengths as well as needs is great and far more positive than traditional deficit models of seeing everyone just as a problem to be fixed. Defining people only by their needs or cost to ‘the system’ is dehumanising, because people have feelings. But things don’t – we don’t need to worry about upsetting a tower block or an abandoned car park. We should be brave and honest enough to acknowledge when a place – a neighbourhood, an estate, a single building – is crap and making people ill and unhappy and that even the best, most committed of residents can’t be asset-based-community-developed into sorting everything out themselves. It’s not their fault, such places have been let down by the poor decisions of successive local and national governments, and I think residents are right to expect the responsibility to rectify those decisions to lie primarily with those in charge.
Below I run through some ideas on how decision makers might focus on places to improve wellbeing. I’m not going to talk about the more obvious things like the need for jobs and schools and decent housing and parks, these are a given. Instead I’m going to talk about less tangible things that might not have been thought about as much in terms of prevention. Hopefully that’s not because they’re a load of tangential rubbish.
Base strategic ‘places’ on community identity
I’ll start with identity. People like to belong to somewhere or something. We’ve lost a lot of the jobs that provided that sense of identity, either because industries have disappeared (like mining) or been privatised into something less meaningful. My Dad often talks about how the culture of public service, respect and sense of worth changed for the worse when British Telecom became BT. I think maybe this loss of identity is worse in England; I’m always a bit jealous of the Scots, Welsh and Irish, they really celebrate their traditions, but Englishness seems to have been tainted by association with football hooliganism and the far-right decades ago. I think this human need for a sense of belonging but a lack of productive ways to gain and maintain it nowadays contributes to the tribalism we see.
People still identify with places though. There is lots of talk about ‘place-based’ approaches to health at the minute. This is welcome, even if in the main this has been in terms of organisations working together to integrate health and care services, and less about making somewhere a better place to live more generally. But these strategic ‘places’ are often artificial and don’t resemble real places that real people relate to. For example, I feel Barrovian, Cumbrian, Northern, English and British; I feel like an adopted Scouser and part of my local neighbourhood. And yet look at the NHS’ sustainability and transformation partnerships – my home town is now part of a newly-baptised ‘Lancashire and South Cumbria’ region. I struggle to relate to that. And nobody is going to a buy a ‘I went to Bath and North East Somerset, Swindon and Wiltshire and all I got was this lousy t-shirt’ top are they? Some of the STP areas come across like NHS England spent two weeks drinking heavily then spent five panicked minutes randomly poking at a map with a sausage.
‘Place-based’ approaches make much more sense when they focus on areas that people genuinely identify with. The Health Foundation talks about the need to work with ‘authentic communities’, “those who […] identify with each other and recognise themselves as a community or group with shared activities and aspirations”. Perhaps we need to think less ‘place-based’ and more ‘community-focussed’. And let’s stop imposing and redrawing artificial boundaries from on high every few years. There are people in Barrow still furious about being booted out of Lancashire in 1974…
The ‘feel’ of a place
I’ve become more and more interested in the link between buildings, people’s familiarity with where they live, their sense of identity, civic pride, and wellbeing (and I’ve recently started following CreateStreets’ work on what ‘makes’ a place – their free eBook is worth a look, as is this report from Historic England, the British Property Federation and the Royal Institution of Chartered Surveyors). Historic buildings – and I’m not just talking about grand ‘heritage’ buildings, but anything that’s been there long enough to feel part of the fabric of a place – provide a focal point for people and a sense of familiarity, of belonging. It might be that they have a personal connection to them; perhaps they went to school in this building or used to buy sweets from that one – or that this one has just always been there, a constant in an otherwise changing world. A bit like Sir Alex Ferguson was for me growing up…
In general, people don’t like too much change too quickly. When people complain about immigration or gentrification or tourism changing the ‘feel’ of a place, they often get dismissed with accusations of racism or of failing to embrace progress. I’m not one for name calling and would much rather try and understand why people feel a certain way; I actually think it’s a natural thing for people to be upset when a place they call home no longer feels familiar to them, for whatever reason. I was gutted when my beautiful old school was demolished, despite not having lived in the town for nearly twenty years. Whenever I go home I still feel a horrible hollow anger whenever I see the generic housing estate it was replaced with.
My point is that how a place feels is important; familiarity gives meaning to people, and we’re too quick in knocking down familiar old buildings and chucking up others of a completely different – or no – character. More and more places have become soulless ‘clone towns’. We should relish all the heritage of our towns and cities and not just the grand cathedrals and museums; personally, I think it’s the more everyday buildings that give a place and its people their identity. We can never get back what we’ve lost, and we don’t really know how that affects people’s wellbeing. More research please, researchers.
Power to the people
I’ve talked before about how we as professionals often speak a different language to the public. Our ‘engagement’ with local residents can often seem superficial and I’m rarely convinced that our priorities match theirs, even when we have the best intentions. You only have to glance at Twitter to see the level of anger currently from people who feel they’re not listened to. That’s why I’m excited by the increase in participatory democratic approaches like citizen’s assemblies, as a way to both identify what really matters to people and to give them power to be part of the solution, as they were in Ireland’s abortion debate. More of this sort of thing please. We should ask people directly what would improve their area, what would make them happier. Posh areas might say an organic butchers, poorer places might say buses; either way it’s fantastically useful information. Adam Lent and Jess Studdert from NLGN have put forward some great arguments for relinquishing decision-making powers to communities; Dave Buck and Lillie Wenzel from the King’s Fund have written a good introduction; and this article has some interesting examples of it happening in practice.
Neighbourhoods versus whole regions
In public health we often talk about Geoffrey Rose’s two approaches to prevention. The ‘high risk’ strategy is where we target resources towards those relatively few individuals at high risk of a health problem. An example might be weight loss surgery for obesity – a few morbidly obese individuals may benefit immensely from an intervention like this, but it would make little difference to obesity levels within the whole population. The ‘population’ strategy instead attempts to reduce the level of risk across the whole population. Here, any one person’s decision to lose a little weight may have a small impact on their own risk of disease, but if many people each lose a little bit of weight then this can have a huge impact at the population level.
We need to do both but generally have the balance wrong, tending to put too much emphasis on individuals at high-risk and not enough on improving the health of whole populations. When we talk about places I think the balance goes the other way – we do too little of the more targeted stuff.
You often here things like “this investment will be good for the entire region!” or “a boost for the whole city!” when some new money or jobs come in. But, in reality, we know a boost to a region’s GDP might look good on a spreadsheet but it rarely makes any difference to the neighbourhoods that are in most need. Most people there don’t feel 2% happier when the economy grows by 2%. Nice parts get nicer whilst, in a lot of places I’ve visited, the areas that were poor and neglected 30 years ago are still relatively poor and neglected now.
We’re very happy to identify groups of people that need extra help and target them – we do that less with places. It should be possible to think, “right, the city as a whole is doing pretty well but this neighbourhood isn’t – let’s focus on improving there”. Wakefield DPH Anna Hartley does a great job in this article of arguing for a neighbourhood approach.
I’m not a big fan of the idea of a universal basic income (UBI), though I know a lot of people find the idea appealing. There are various reasons why I’m not too keen, but I can probably sum it up by asking: what good is having a bit of extra money to get the bus to work if there is no bus to work?
I am a big fan of the idea of universal basic services (UBS), “the provision of sufficient free public services, as can be afforded from a reasonable tax on incomes, to enable every citizen’s safety, opportunity, and participation”. In the UK we already have (almost) free, (almost) universal access to education and healthcare, but proponents of UBS would go further with free basic services to provide shelter, sustenance, public transport, Internet access, and legal support. The knowledge that no matter what happens or where you live you would always have these things, that to live a basic life could effectively cost nothing, would be a powerful social safety net. The Institute of Global Prosperity has done a lot of work on UBS and believe it to be more effective and affordable than UBI. There is still a heathy debate on this and these podcasts from the New Economics Foundation and Reasons to Be Cheerful (again) are a good listen.
The idea of UBS encourages thinking about what should be freely available to all. Just the above? Childcare? Sports facilities? What should a ‘minimum set of assets’ for a place look like? Should everybody be within a mile of a shop selling fresh food? A swimming pool? Good quality public green space? When I was growing up, my primary school field was full every evening and weekend with literally dozens of local children playing football or rounders or British Bulldogs. All the schools are fenced off now, so if you can’t bum a lift to the leisure centre, and afford a fiver, you can’t play.
Some of the stuff above requires courage – to admit when policies were wrong, or to hand over power. But the climate is knackered, we’re wrecking our own gaff, inequality is still awful, and the worst thing is we have the tools to fix most of this stuff. We might, eventually, but we’re often too frightened to do the right things right now at risk of upsetting the status quo. I’d love to see a bit of bravery, to just get on and do it. Other countries do – they’ve banned cars in city centres, for example. It’s annoying for some, for a bit, then all of a sudden it’s just part of life. We know what we need to do, we know where the world is heading. Just do it.
Perhaps we also need to be brave enough to say no – we keep saying yes to bigger, shinier, busier, in the name of growth. Our cities are growing at the expense of our towns, despite evidence that cities are increasingly bad for our health. Real bravery might be saying no to snazzy new developments, to forgo growth for growth’s sake, because residents are happy with what they already have.
Much of what I’ve written might not objectively improve what we currently measure as ‘health outcomes’ in the short term, but I think has real potential to improve subjective wellbeing, that more elusive feeling of how content we are with our lives. And I’m a big fan of that.
Lastly, a note about positivity and honesty. I know, I know; after saying the term ‘prevention’ is too negative I banged on about shit lives and shit places. You can’t actually go around designating places as Officially Shit, I know that. Where you’re from is a bit like your wife or your mum; it’s ok if you make a joke about them but nobody else can. But I’ve used these terms to be provocative, to make the point that we have to be honest and admit when a policy hasn’t worked, or when a place just needs proper help, or when the best ways to improve health and wellbeing have nothing to do with health care. I think that honesty helped to save Liverpool, for example. The admission that Liverpool had hit rock-bottom in the 1980s and needed help and radical change was one of the catalysts for its recovery.
In the real world, we need to be much more positive than my Shit Life Reduction Strategy. There are already good examples of visions focussing less on preventing poor health and more on the enormous benefits of enabling good lives and actively creating good health and wellbeing: Northern Ireland’s Making Life Better strategy, the New NHS Alliance’s Manifesto for Health Creation and the Health Foundation’s recent Creating Healthy Lives report, for example.
I’m sure that I’ve been over-simplistic or naïve in places here – I’m still relatively new to public health and very new to the politics of it all. Some of what I’ve discussed would require more money and devolved power to local areas. But, I hope, if nothing else, this has offered some food for thought about things that wouldn’t ordinarily make it into a prevention strategy. As ever, agree or disagree, you can let me know on Twitter.